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ARM•01;2(Rev. 11/83) Attach to Wisconsin Income Tax Schedule FC ZONING CERTIFICATE — FARMLAND PRESERVATION ACT — STATE OF WISCONSIN (1) Name of Owner(s) Nelson Thomas & Jerry (Last) (First) (Middle Initial) (2) Mailing Address of Owner 4239 Gotzion Road, Deerfield, WZIPCode 53531 (3)Phone 764-8432 (4) Location of the land nes.rf i e 1 r1 Secs 21, 28 T7N R12E Dane Town,Village,or City Section,Township, Range County (If part of the owner's farmland is located in another town,village, or city,please submit information about that farmland on a separate form.) EXCLUSIVE AGRICULTURAL ZONING (5) Dane has an exclusive agricultural zoning ordinance which has been certified (County,Town,Village or City) by the State Land Conservation Board on (date) October 26. 1978 • (6) Check below the type of ordinance jurisdiction which applies and give the date of local approval (effective date of ordinance). nTown under county exclusive agricultural zoning. Local approval date ❑ Town with separate town ordinance. Local approval date ❑ City or village: Check one or both below. 1 I Within corporate limits. Local approval date nExtraterritorial. Local approval date (7) Does each structure or improvement on the land conform to the requirements of the exclusive agricultural zoning ordinance? Yes No ❑ Land on which tax credit is claimed: (8) Parcel No. (from tax rolls) (9) Total Acres in Parcel (10) Acres in Exclusive Ag. District 12-21-484 40.3 36.6 12-28-637.3 30.0 30.0 Total 70.3 Total 66.6 AGRICULTURAL PRESERVATION PLAN (11) Dane County has adopted an agricultural preservation plan which was certified on (date) 12/4/81 by the State Land Conservation Board. CERTIFICATION Signature of Zoning Authority Program Year Title ZONING ADMINISTRATOR Date RE-CERTIFICATION (Note:If any of the above information has changed,please submit a new zoning certificate.) The undersigned hereby certifies that the information contained on this form is true and correct on the most recent date shown below. 1. Signature of Zoning Authority Title Date Program Year 2. Signature of Zoning Authority Title Date Program Year 3. Signature of Zoning Authority Title Date Program Year 4. Signature of Zoning Authority Title Date Program Year (The land must be in an exclusive agricultural zone on Dec. 31 of the year for which credit is being claimed. This certificate, along with property tax bills, must be included with the Schedule FC when credit claim is filed with the Wisconsin Department of Revenue.)